Studentenversicherung -
- Statutory health insurance for students

Students insurance - - Statutory health insurance for students

online application

Instructions on completing the form

Help: auxiliary information you will find touching the next to the respective fields.

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Internet Explorer 6.0+

Click the Tools menu.
Select Internet Options.
Click the Security tab.
Click the Custom Level button.
Scroll down until you see the 'Scripting' section. Select the 'Enable' radio button for 'Active Scripting.'
Click the OK button.
If you see a confirmation window, click the Yes button.

Please enter German or Austrian current accounts only, because we can only do direct debit in those countries. In case of the SEPA direct debit method, the premiums due will be collected shortly before the period of coverage to which the premiums due relate. A few days before we will send you a pre-notification. If you choose for payment at once, the entire insurance premium will be collected at the beginning of the period of coverage.

The premium will be debited on the 25th of the current month. Please make sure the premium requested is covered by the funds in your account on that date! The premium has to be paid for the entire semester, even during school breaks, trips home or vacations. If the premium is not paid, the university/college will deny registration or refuse to accept you back -> exmatriculation!

The insurance premium will be debited monthly from the checking account provided.

Please select how you would like to pay the insurance premium

Do you already have a bank account in Germany?YesNo

Direct debit monthly
(Payment is only possible by direct debit)

Are you the account holder?YesNo

I certify that I am authorized by the account holder to operate the aforementioned account, to express and receive declarations of intention for him and that I will forward all messages in the context of the SEPA direct debit mandate to the account holder.YesNo

So that we can collect the SEPA direct debit from the indicated account, we need the name and surname of the account holder and a SEPA direct debit mandate. The mandate will be deposited with us as a PDF document to your payment details. You will receive the mandate as a PDF, sent to the e-mail address you provided. Please enter below the data of the account holder:

Account holder:First name Last name

As part of the SEPA migration enacted by the EU, you must state your BIC instead of your bank code and your IBAN instead of the account number. These can be found, depending on the bank, on your debit card or on your bank statement. If the BIC and IBAN cannot be found out, you can contact us for your support by dialing +49 228 97735-44, +49 228 97735-11 or +49 228 97735-33.

So that we can collect the SEPA direct debit from the indicated account, we need a SEPA direct debit mandate. The mandate will be deposited with us as a PDF document to your payment details. You will receive the mandate as a PDF, sent to the e-mail address you provided.

BIC

IBAN

Bank name

Account holder

Please enter German or Austrian current accounts only, because we can only do direct debit in those countries. In case of the SEPA direct debit method, the premiums due will be collected shortly before the period of coverage to which the premiums due relate. A few days before we will send you a pre-notification. If you choose for payment at once, the entire insurance premium will be collected at the beginning of the period of coverage.

The premium will be debited on the 25th of the current month. Please make sure the premium requested is covered by the funds in your account on that date! The premium has to be paid for the entire semester, even during school breaks, trips home or vacations. If the premium is not paid, the university/college will deny registration or refuse to accept you back -> exmatriculation!

The insurance premium will be debited monthly from the checking account provided.

Payment per month is only possible via direct debit and for a duration of coverage starting at 180 days. In this case the monthly premium is EUR 50 for persons up to 64 years old and EUR 126 for persons between 65 and 73 years old.

Additional contact information in the event of questions

e-mail

Area code*

Telephone*

Fax no.*

How did you find us?*

Tipp for qq-user:To be sure that you receive all documents, please fill in another (not qq-)e-mail in the field for the second e-mail

Here you can fill in a further e-mail-address, to which we will send the insurance documents aditionally.*

The fields marked with an * asterisk are not required to take out a policy, but the information provided makes it easier for us to contact you. You will not receive any unsolicited advertising material via email, and we will not forward your information on to any third parties.

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Referrer / agent number

Agency number or agent number at the Care Concept AG =>

Terms and conditions health insurance

By clicking on the adjoining field you confirm that you have read, understoodd and agreed to the following conditions. At the same time you are confirming that you have printed and / or downloaded the following conditions:

By clicking on the adjoining field you confirm that you have read, understoodd and agreed to the following conditions At the same time you are confirming that you have printed and / or downloaded the following conditions: